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ROGER JONES ET AL. 2005. OXFORD TEXTBOOK OF PRIMARY MEDICAL CARE. OXFORD

UNIVERSITY PRESS


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Principles of Pathophysiology and Emergency Medical CareOleh Jeffrey W. Myers,Marianne Neighbors,Ruth Tannehill-Jones


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http://www.medicinenet.com/internal_bleeding/article.htm

What is internal bleeding?

While the general public understands that internal bleeding means bleeding that can't be seenon the outside of the body, medical personnel tend to use terms that describe precisely whereinside the body the bleeding is found. The internal bleeding may occur within tissues, organs, orincavitiesof the body including the head, chest, and abdomen. Examples of other potential sites of

bleeding include the eye, lining tissues of the heart, muscles, and joints.Bleeding outside the body is quite easy to recognize. If the skin is damaged by

alaceration,puncture, orabrasion, blood can be witnessed as it streams out of the body. Thescalp, with its rich blood supply, is notorious for demonstrating massive blood loss. Internalbleeding can be much more difficult to identify. It may not be evident for many hours after it begins,and symptoms occur when there is significant blood loss or if ablood clotis large enough tocompress an organ and prevent it from functioning properly.

Internal bleeding occurs when damage to anarteryorveinallows blood to escapethecirculatory systemand collect inside the body. The amount of bleeding depends upon theamount of damage to an organ and the blood vessels that supply it, as well as the body's ability torepair breaks in the walls of the blood vessels. The repair mechanisms available include both theblood clotting system and the ability of blood vessels to go intospasmto decrease blood flow to aninjured area.

Patients who take anti-clotting medication such aswarfarin(Coumadin),clopidogrel(Plavix),heparin, oraspirinare more prone to bleeding than people who do not take these medications.These individuals may experience significant bleeding even with relatively minor injury or illness,and the risk of bleeding needs to be balanced against the benefits of taking the medication.

Some people havegeneticor inborn errors of the blood clotting system. Minor injuries maycause major bleeding in these cases.Hemophiliaandvon Willebrand diseaseare two examples

What causes internal bleeding?Bleeding most often occurs due to injury, and depending upon the circumstances, the amount of

force required to cause bleeding can be quite variable.

Blunt trauma

Most people understand that falling from a height or being involved in a car accident can inflict

great force andtraumaupon the body. If blunt force is involved, the outside of the body may not

necessarily be damaged, but enough compression may occur to internal organs to cause injury

and bleeding.

Imagine a football player being speared by a helmet to the abdomen. The spleenorlivermaybe compressed by the force and cause bleeding inside the organ. If the hit is hard enough,the capsule or lining of the organ can be torn, and the bleeding can spill intotheperitoneum(the space in the abdominal cavity that contains abdominal organs such asthe intestines, liver, and spleen).

If the injury occurs in the area of the back or flank, where the kidney is located, retroperitonealbleeding (retro=behind; behind theabdominal cavity) may occur.

The same mechanism causes bleeding due to crush injuries. For example, when a weightfalls on a foot, the weight doesn't give, nor does the ground. The force needs to be absorbed

by either the bone or the muscles of the foot. This can cause the bone to break and/or themuscle fibers to tear and bleed.
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Other structures are compressible and may cause internal bleeding. For example, the eye canbe compressed in the orbit when it is hit by a fist or a ball. The globe deforms and springsback to its original shape. Intraorbitalhemorrhagemay occur.

Deceleration traumaDeceleration may cause organs in the body to be shifted inside the body. This may shear bloodvessels away from the organ and cause bleeding to occur. This is often the mechanismforintracranial bleedingsuch asepiduralorsubduralhematomas. Force applied to the headcauses an acceleration/deceleration injury to the brain, causing the brain to "bounce around" insidethe skull. This can tear some of the small veins on the surface of the brain and cause bleeding.Since the brain is encased in the skull, which is a solid structure, even a small amount of blood canincrease pressure inside the skull and decrease brain function.

FracturesBleeding may occur with broken bones. Bones contain thebone marrowin which blood productionoccurs. They have rich blood supplies, and significant amounts of blood can be lost with fractures.The break of a long bone such as thefemur(thigh bone) can result in the loss of one unit (350-500cc) of blood. Flat bones such as the pelvis require much more force to cause a fracture, andmany blood vessels that surround the structure can be torn by the trauma and cause massivebleeding.

PregnancyBleeding inpregnancyis never normal, though not uncommon in the first trimester, and is a sign ofa potentialmiscarriage. Early on, the concern is a potentialectopic or tubal pregnancy, in whichtheplacentaand the fetus implant in theFallopian tubeor another location outside of the uterinecavity. As the placenta grows, it erodes through the tube or other involved organs and may causefatal bleeding.Bleeding after 20 weeks of pregnancy may be due toplacenta previaor placental abruption, andurgent medical care should be accessed. Placenta previa describes the situation in which theplacenta attaches to theuterusclose to the opening of thecervixand may cause painlessvaginalbleeding. Abruption occurs when the placenta partially separates from the uterine wall and causes

significant pain with or without bleeding from thevagina.

Spontaneous bleedingInternal bleeding may occur spontaneously, especially in those people who take anticoagulationmedications or who have inherited bleeding disorders. Routine bumps that occur in daily life maycause significant bleeding issues.

MedicationInternal bleeding may be caused as a side effect of medications (most often from nonsteroidalantiinflammatory drugssuch asibuprofenand aspirin) and alcohol. These substances can causeinflammation and bleeding of theesophagus,stomach, andduodenum, the first part of thesmall

intestineas it leaves the stomach.

Alcohol abuseLong-termalcohol abusecan also cause liver damage, which can cause bleeding problemsthrough a variety of mechanisms.

What are the signs and symptoms of internal bleeding?

The symptoms of internal bleeding depend upon where the bleeding is located, how muchbleeding has occurred, and what structures and functions in the body are affected. Blood outsidethe circulatory system (the heart and blood vessels) is very irritating to tissues, causing

inflammation and pain. Examples of some internal bleeding situations are listed below.Intracranial bleeding from trauma or from a leakinganeurysmoften causes pain but may alsopresent with altered mental function.Neurologicalexam results range from a near-normal exam
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toconfusiontocoma. Symptoms ofstroke, includingweakness, slurred speech, and loss of vision,may also be associated with intracerebral bleeding. The signs and symptoms depend upon whereand how much blood there is in the brain. If the bleeding continues, symptoms becomeprogressive and easier to recognize.

Intra-abdominal bleeding may be hidden and present only with pain, but if there is enough bloodloss, the patient may complain of weakness,lightheadedness,shortness of breath, and othersymptoms ofshockanddecreased blood pressure. Once again, the symptoms depend upon wherein the abdomen the bleeding occurs.

If there is gastrointestinal bleeding, the patient mayvomitbright red blood, or if it has been inthe stomach for a period of time, the vomit may look like coffee grounds. Bowel movementsmay be bloody or they may beblack and tarry, again depending upon the location of thebleeding in the gastrointestinal tract.

If the internal bleeding causes blood to spill into the peritoneum, there can be a significantamount of pain with any movement, and the abdomen can become tense and feel rigid totouch.

Sometimes intra-abdominal blood will track toward the skin and can be appreciated onphysical examination. Cullen's sign is the term used to refer to the appearance of bruising

surrounding theumbilicus. Grey-Turner sign is bruising in the flanks.Blood seen in the urine may be due to internal bleeding at any site within the urinary tract, from

the kidney to the bladder. Oftenbladder infectionsare associated withblood in the urinebut other

causes need to be considered based upon the particular symptoms as well as the patient's age

andmedical history, especially males who may have had prostate surgery. Men and women who

have hadradiation therapymay develop inflammation of the bladder wall which can cause a

significant amount of bleeding.

Bleeding may occur deep within muscles after injury, and rarely,compartment syndromemay

occur. Should so much bleeding occur that the pressure build-up within the muscle is greater than

the patient's blood pressure, blood cannot get to the muscle cells, and they begin to die.

Symptoms include intense pain, difficulty moving the joints below the injury, and loss of sensation.

Most commonly this is seen in the shin and forearm and may or may not be associated with a

broken bone.

Bleeding may also occur into joints, causing significant pain and loss ofrange of motion. This

most frequently is seen in patients who are on anti-coagulation medications. An injury may or may

not be needed to cause the bleeding.

How is internal bleeding diagnosed?

The diagnosis of internal bleeding begins with a thorough history taken by the health carepractitioner. This is followed by a physical examination, concentrating on the area of the bodywhere the internal bleeding may have occurred. For example, if there is concern about bleeding inthe brain, the physical examination will focus on the neurologic system, or if it is intra-abdominalbleeding, the exam will be directed toward the abdomen.

Blood tests may be performed to check for alow red blood cell count, oranemia. However, if thebleeding occurs rapidly, the initialhemoglobinreading or red blood cell count may be normal.

The suspicion of internal bleeding will often require an imaging test to look for the bleedingsource.

If there is concern that there is gastrointestinal bleeding, agastroenterologistmay use fiberoptic scopes to look into the esophagus and stomach (endoscopy) or into the colon(colonoscopy) to identify the source. If found, the physician may be able to stop the bleedingusing electricity to cauterize or burn the blood vessel that is bleeding.
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Computerized tomography(CT) is the most common test to look for bleeding in the brain. It isalso able to identifybrain swellingand fractures of the skull.

Ultrasoundmay be used to look for blood in the abdomen. While it has its place in themanagement of trauma, ultrasound is especially useful in evaluating obstetric andgynecologic problems such as bleeding from anovarian cystor an ectopic or tubal pregnancy.

Computerized tomography is an effective tool in looking for intra-abdominal andretroperitoneal bleeding. It can evaluate the potential injury site, the severity of organ damage,

and whether the bleeding is contained within an organ (such as the liver, kidney or spleen) orwhether the bleeding has spilled into the peritoneum. It is also a helpful test in assessingpelvic fractures.

If the source of bleeding is thought to be due to a damaged artery,angiographymay be usedto evaluate the arterial blood flow.

In some situations in which the patient is critically ill from internal bleeding, the decision may bemade to undergo emergency surgery to find and repair the bleeding site. This may occur in traumavictims with abdominal or chest injuries who have unstable vital signs (decreased level ofconsciousness,low blood pressure, and other signs of shock) and are at risk for bleeding to death ifthey were to wait for diagnostic tests.

A person may be bleeding internally if one of these things happens:

Blood comes out of the nose or mouth (occurs from severe head trauma)

Blood or clear fluid comes out of the ear (occurs from severe head trauma)

Blood is in the stool

Blood is in the urine

Bright red blood, or blood like 'coffee-grounds', is in the vomit

Blood comes from a woman's vagina (birth canal) after an injury or during pregnancy

Bruising over the abdominal or chest area

Pain over vital organs

Fractured femur

But remember, a person may be bleeding inside the body, even though you cannot see the bleeding. If

you see the signs of shock and no apparent injuries, always suspect internal bleeding. Check the skin

color changes. In cases of internal bleeding the skin may become pale and cold, and cyanosis may be

present.

How is internal bleeding treated?The initial treatment plan of any patient with internal bleeding begins with assessing the patient's

stability and making certain the ABCs are well maintained. This includes making certain the

patient's:

Airway is open,

that the patient is Breathing, and

that there is adequate Circulation, meaning good pulse and blood pressure.

The definitive treatment of internal bleeding depends upon where the bleeding is occuring, the

individual situation, and the stability of the patient. The basic goals include identifying and stoppingthe source of bleeding and repairing any damage that the bleeding may have caused.
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What are the complications of internal bleeding?

Depending upon where it occurs, if not recognized, internal bleeding may causeorgan failure,

shock, and death. For example:

If there is uncontrolled bleeding in the chest or abdomen, the body may lose enough

circulatingred blood cellsto compromise oxygen delivery to cells in the body. This situation is

called shock. If the bleeding is not stopped and if fluid resuscitation and perhapsblood

transfusionare not provided, the patient may die.

Internal bleeding in the brain may cause minimal damage, but if there is enough to cause

increased pressure or if the bleeding increases, enough brain tissue may be damaged to

cause stroke-like symptoms, coma, and death.

Internal Bleeding At A Glance

Internal bleeding may occur in many areas of the body and may cause significant local pain. Ifenough bleeding occurs, signs of shock may be apparent.

Bleeding is a recognized complication of anti-coagulation medications such as aspirin,clopidogrel (Plavix), warfarin (Warfarin), and heparin. The benefits of these medications needto be balanced against the risk of bleeding.

Bleeding is never normal in pregnancy.

If internal bleeding is suspected, it is important to seek medical care.

External BleedingBleeding is a common reason for the application of first aid measures and can be internal orexternal. The principle difference is whether the blood leaves the body - external bleeding canbe seen, whereas in internal bleeding, no blood can be seen.

There are many causes of external bleeding, which fall in to seven main categories, which are:

Abrasion - Also called a graze, this is caused by transverse action of a foreign objectagainst the skin, and usually does not penetrate below the epidermis

Excoriation - In common with Abrasion, this is caused by mechanical destruction of theskin, although it usually has an underlying medical cause

Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue ortearing such as in childbirth

Incision - A clean 'surgical' wound, caused by a sharp object, such as a knife

Puncture Wound - Caused by an object penetrated the skin and underlying layers, suchas a nail, needle or knife

Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under thesurface of the skin

Gunshot wounds - Caused by a projectile weapon, this may include two external wounds(entry and exit) and a contiguous wound between the two
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Recognition

Recognizing external bleeding is usually easy, as the presence of blood should alert you to it.It should however be remembered that blood may be underneath or behind a victim. It may bedifficult to find the source of bleeding, especially with large wounds or (even quite small)wounds with large amounts of bleeding. If there is more than 5 cups of bleeding, then thesituation is life-threatening.

Treatment

As with all first aid situations, the priority is to protect yourself, so put on protective glovesbefore approaching the victim.

All external bleeding is treated using three key techniques, which allow the body's naturalrepair process to start. These can be remembered using the acronym mnemonic 'RED':

Rest ElevationDirect pressure

RestIn all cases, the less movement the wound undergoes, the easier the healing process will be,so rest is advised. Rest will also reduce the pulse rate, thus the severity of the bleeding,especially in the case of arterial bleeding.

Elevation

Direct pressure is usually enough to stop most minor bleeds, but for larger bleeds, it may benecessary to elevate the wound above the level of the heart (whilst maintaining directpressure the whole time). This decreases the blood flow to the affected area, slowing theblood flow, and assisting clotting.

Elevation only works on the peripheries of the body (limbs and head) and is not appropriatefor body wounds. You should ask the victim to hold their wound as high as possible. Youshould assist them to do this if necessary, and use furniture or surrounding items to helpsupport them in this position. If it is the legs affected, you should lie them on their back(supine), and raise their legs.

Direct Pressure

The most important of these three is direct pressure. This is simply placing pressure on thewound in order to stem the flow of blood. This is best done using a dressing, such as a sterilegauze pad (although in an emergency, any material is suitable).

If the blood starts to come through the dressing you are using, add additional dressings to thetop, to a maximum of three. If you reach three dressings, you should remove all but the onein contact with the wound itself (as this may cause it to reopen) and continue to add pads ontop. Repeat this again when you reach three dressings. The reason for not simply addingmore dressings is that it becomes harder to apply the direct pressure which is clearly neededif this much blood is produced.

Where an articulate area of the body is wounded (such as the arms or hands), it is importantto consider the position of the area in keeping pressure on the wound. For example, if a handis cut 'across' from the thumb to halfway across the palm, the wound can be closed withdirect pressure by simply clasping the victim's hand shut. However, if the hand was wounded

from between the two middle fingers down to the wrist, closing the hand would have theeffect of opening the wound, and so the victim should have their hand kept flat.


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In most cases, during the initial treatment of the bleed, you will apply pressure by hand inorder to stem the flow of blood. In some cases, a dressing may help you do this as it cankeep pressure consistently on the wound. If you stop the flow by hand, you should thenconsider dressing the wound properly, as below.

Dressing

Once the bleeding is slowed or stopped, or in some cases, to assist the slowing of the blood

flow you should consider dressing the wound properly.To dress a wound, use a sterile low-adherent pad, which will not stick to the wound, but willabsorb the blood coming from it. Once this is in place, wrap a crepe or conforming bandagearound firmly. It should be tight enough to apply some direct pressure, but should not be sotight as to cut blood flow off below the bandage. A simple check for the bandage being tootight on a limb wound is a capillary refill check; to do this, hold the hand or foot (dependent onwhat limb is injured) above the level of the heart and firmly pinch the nail. If it takes more than2 seconds for the pink color to return under the nail, then the bandage is likely to be too tight.

If the blood starts to come through the dressing you have applied, add another on top, to amaximum of three. If these are all saturated, remove the top two, leaving the closest dressing

to the wound in place. This ensures that any blood clots that have formed are not disturbed;otherwise, the wound would be opened anew.

Special cases

Nosebleeds (epistaxis)

If a person has nosebleed, have them pinch the soft part of the nose firmly betweenthumb and forefinger, just below the end of the bone. If necessary, do this yourself, but it ispreferable to have them do it themselves if they are able to do it effectively.

The victim should lean their head slightly forward and breathe through their mouth. You

can also leave the head in a neutral position, but never tilt the head back. Tilting the headforward ensures that blood isn't ingested (as it can cause vomiting) or inhaled (chokinghazard).

If you are unsuccessful at stopping the bleeding after 10 minutes of direct pressure, youshould assess the blood flow. If the blood flow is minor, you could consider using an icepack on the bridge of the nose to help stem the flow.

If the nose continues to bleed with a fast flow, you should seek medical assistance,probably from the ambulance.

Embedded Objects

If there is something embedded in the wound, do not remove it. Instead, applypressure around the object using sterile gauze as described above. Rolled bandages areperfect for this. Be careful not to disturb the object, as moving it may exacerbate thebleeding. This doesn't apply to superficial splinters and such. A useful rule of thumb: if it'scausing bleeding, don't remove it. If it isn't, feel free.

Stab, puncture or gunshot wounds to the body

These wounds are life threatening, and after assessing the ABCs of the victim, you shouldimmediately summon an ambulance. As always, you should check that you are not indanger when approaching these victims (from someone with a knife or gun, for instance).As with all embedded objects, ensure you do not remove the item from the body.

If possible, you should sit the victim up (as blood in the body will go to the lowest point,allowing the heart and lungs to work as efficiently as possible). You should also lean themto the injured side, keeping the healthy side free from incursion by blood.


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Assess the victim foropen chest woundsorabdominal injuries, and treat accordingly.

Amputations

If a body part has been amputated, immediately summon ambulance assistance, and treatthe wound for bleeding first as above. Cover the amputated part with a moist dressingand place it in a clean plastic bag, and place this bag into a bag of ice and water, sending itwith the victim to the hospital (it should be labeled with their name, and where it belongs).You should avoid putting the part in direct contact with ice, as this can cause irreparable

damage, meaning that surgeons are unable to reattach it.

If the body part is partially amputated, do not detach, but treat as a wound.
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